Pediatric Orthopedics for Primary Healthcare
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Pediatric Orthopedics for Primary Healthcare
Sattar Alshryda • Lisa Jackson Nandu Thalange • Ali AlHammadi Editors Pediatric Orthopedics for Primary Healthcare Evidence-Based Practice
Editors
Sattar Alshryda Lisa Jackson
Head of Trauma & Orthopaedics Surgery Associate Professor of Family Medicine
Al Jalila Children’s Speciality Hospital College of Medicine
Dubai Mohammed Bin Rashid University of
United Arab Emirates Medicine and Health Sciences
Dubai
Nandu Thalange United Arab Emirates
Consultant Paediatric Endocrinologist
Department of Medical Subspecialties Ali AlHammadi
Al Jalila Children’s Hospital Director of Clinical Planning and Strategic
Dubai Partnerships
United Arab Emirates Al Jalila Children’s Speciality Hospital
Dubai
United Arab Emirates
ISBN 978-3-030-65213-5 ISBN 978-3-030-65214-2 (eBook)
https://doi.org/10.1007/978-3-030-65214-2
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland
AG 2021
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether
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mission or information storage and retrieval, electronic adaptation, computer software, or by similar or
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The use of general descriptive names, registered names, trademarks, service marks, etc. in this publica-
tion does not imply, even in the absence of a specific statement, that such names are exempt from the
relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, expressed or implied, with respect to the material contained herein or for any
errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, SwitzerlandTo children for all the joy and hope that they bring to our life. Sattar Alshryda To my children Harold and Lucy, the MBRU family and my wonderful family medicine colleagues in the UK and United Arab Emirates. Lisa Jackson I would like to thank my dear colleagues past and present, and the children and families who are my teachers and remind me every day why I am a doctor. Nandu Thalange To my parents for their continuous love and support. Ali AlHammadi
Foreword
I am honoured to be asked to write a foreword for this book. As a paediatric ortho-
paedic surgeon married to a family doctor, we saw the need for such a book many
years ago—but with four children of our own, we never seemed to find time our-
selves to write one!
In many medical schools there is less time devoted to orthopaedics as a whole
than there used to be. Very little of that ‘orthopaedic time’ is spent looking at the
problems of children or learning to understand what is normal in the musculoskel-
etal development of children. Considering that musculoskeletal conditions account
for a significant proportion of family doctor consultations, there is clearly a mis-
match between training and the real-life practice it is supposed to be a prepara-
tion for.
This book will increase mutual understanding and knowledge and improve com-
munication between family doctors and paediatric orthopaedic surgeons. As a con-
sequence, it will benefit children and for that the authors are to be congratulated.
Each speciality can learn useful skills from the other. There is an old joke that
says that when orthopaedic surgeons talk about a holistic approach, they are think-
ing about the whole bone. The most memorable humour contains a grain of truth,
and this highlights our tendency to focus down on the tree rather than standing back
to see the whole wood. Within this book, paediatric orthopaedic surgeons can learn
how to see orthopaedic conditions holistically within the context of the other issues
in the child’s life.
The family doctor may also gain much from the text. Within a family doctor’s
practice, children’s orthopaedic conditions are only a small part. Some important
conditions with life-altering consequences (such as slipped upper femoral epiphy-
sis) may only present once, insidiously, in a family doctor’s career. It is vital that
when it does, the diagnosis is considered, and referral initiated. This is a huge diag-
nostic challenge, but not an impossible one, if we learn the lessons in this book.
viiviii Foreword
The book also goes some way to demystify the terminology of orthopaedics—
the language that is as foreign to medical colleagues as a cardiology report is to us!
I am sure this book will be successful, and deservedly so. It just remains for me
to extend my thanks to all the contributors, on behalf of the readership.
Richard Montgomery, FRCS (Ed), FRCS (Eng)
British Limb Reconstruction Society
London, UK
British Society of Children Orthopaedic Surgeons
London, UK
British Society for Surgery in Cerebral Palsy
Lincoln, UK
Council of British Orthopaedic Association
London, UK
Royal College of Edinburgh
Edinburgh, Scotland
Intercollegiate Specialty Board in T&O Surgery
(FRCS T&O Exam Board)
London, UKForeword
Where is the Wisdom we have lost in Knowledge?
Where is the Knowledge we have lost in Information?
Where is the Information we have lost in the Internet. (Apologies to T.S. Eliot!)
I felt honoured and privileged when Lisa and Nandu Thalange approached me to
write a foreword for this textbook, given our shared passion for primary care (family
medicine), neuromusculoskeletal problems in children and medical education! I am
deeply grateful to the editorial team who live by the philosophy of lifelong learning.
I would hope that my experience of learning, sharing and working in and across
continents for nearly half a century, as a specialist in orthopaedics and as a general-
ist family physician, would be relevant in writing this foreword.
Paediatric orthopaedics as a subspeciality has grown and developed immensely
over the last two decades. The term orthopedia was coined by Nicolas Andry (a
French Professor of Medicine in Paris) in 1741, from two Greek words orthos
(straight) and pais (Child) in his treatise On the Art of Correcting and Preventing
Deformities in Children. About 25% of all consultations in primary care are for
musculoskeletal problems. Paediatric orthopaedics demands a deeper knowledge of
the normal and abnormal growth and development and understanding of the muscu-
loskeletal system, beyond clinical anatomy.
This book is the distilled product of the experience of both primary care physi-
cians and secondary care specialists. Experience goes beyond exposure, encom-
passing knowledge, understanding, application of knowledge in different settings,
analysing outcomes and reflecting on them and synthesising internally. Every con-
tributor has been carefully chosen by the editorial team. Every chapter has been
written by the collaboration, communication and commitment of community-based
and hospital-based specialists, from different continents, covering the journey of the
patient from his home to the hospital settings. This nosegay of experience from
multinational authors has been thoughtfully tied together by the four editors ensur-
ing relevance to primary care physicians. The book is divided into a general section
of 13 chapters and a regional section of 7 chapters, addressing the common prob-
lems by anatomical region. Real-world case histories add relevance to the primary
care practice. For example in Chapter one, Case study 1.1 is an excellent example
of real-world problems in the context of primary care. The author then explores the
semantics of terminology that underpins the clinical problem. The relevant
ixx Foreword
illustrations, photographs and tables enhance understanding. Another useful theme
is the Abstract and Key words, which focuses on the salient contents of what fol-
lows. It enables the reader to pause and review what is already known about the
problem, before perusing the rest of the chapter and finally asking the question
‘What next?’ This helps the reader to progress further by accessing the web-based
resources in a more focused way.
The idea for the book was born prior to the global Covid-19 pandemic. The
development and completion of the book, despite the global pandemic, by 38 con-
tributors and four editors is a formidable achievement. The comprehensiveness
makes this book go beyond ‘must-read’ to ‘must-have’ in primary and secondary
care clinics globally. I am confident that this textbook will not only be valuable to
primary care physicians, but to all clinicians dealing with orthopaedic problems in
children, in any setting.
Sidha Sambandan, FRCS, FRCGP, PGDipMSMed
Norwich, Norfolk, United KingdomForeword
The speciality of general practice/family medicine is a challenging one intellectu-
ally because it uses knowledge from all the medical specialities to care for patients
across the lifecycle and with any condition. Recognition of the normal, helping
people to tolerate uncertainty as problems are diagnosed and treated and also under-
standing the aftercare of hospital interventions are all part of the role of primary care
physicians and their teams.
In many countries, the first point of care for children as well as adults is in family
medicine, which again means that family doctors will need to understand the nor-
mal development of the human skeleton and related problems. This book covers the
whole range of issues from normal development to serious pathology such as
tumours, and each chapter’s co-authorship by a generalist and an orthopaedic spe-
cialist ensures that its contents are relevant to the role of primary health care. It
provides in-depth knowledge to support those undertaking speciality training for
family medicine, but also provides updates and revision material useful to practising
family doctors. Some of the topics covered may be quite rare in clinical practice, but
all are potential presentations that a GP will see from time to time: so the text is also
useful as a reference source when patients with paediatric orthopaedic prob-
lems attend.
I congratulate the authors for having the vision to write such a text; to the readers
for being professionally committed to this important area of clinical practice; and to
all those who practise family medicine, as doing the right thing for your child
patients may make a difference to the rest of their lives. Thank you for this book.
Amanda Howe, OBE, FRCGP, FMedSci
Norwich, Norfolk, United Kingdom
xiPreface
Children’s orthopaedics is challenging even for experts in the field. There is a wide
spectrum of normal and abnormal musculoskeletal conditions in children, and the
first port of call for most families is their general practitioner. At one end of the
spectrum, are normal variants that require simple reassurance, and at the other, very
serious and even life-threatening conditions such as bone cancer.
There is a real shortage of information, specifically geared for the needs of pri-
mary care. We attempt to address this deficiency in a comprehensive, evidence-
based and readily comprehensible textbook that gives GPs and others working on
the primary care front line the information required to navigate the complex field of
children’s orthopaedic problems. More than that, we seek to imbue a sense of con-
fidence and partnership, recognising the critical role of the GP in the management
of musculoskeletal conditions.
Doctors’ training has changed dramatically over the last decade. With the intro-
duction of shorter and more specialised competency-based training, few doctors in
primary care will acquire paediatric orthopaedic training. We hope this textbook
will provide a definitive ‘state-of-the-art’ guide to fill this gap.
The book’s contents are divided into general and regional orthopaedics. The
depth of knowledge is appropriate to the general practitioner level with additional
specialist information which may aid explanation and planning discussions between
the primary caregiver, children and carers. Each chapter is written jointly by an
orthopaedic surgeon and a primary care physician, copiously illustrated with clini-
cal photographs, charts and radiographs with concise, evidence-based guidance and
information. We hope you enjoy the fruits of our labours!
Sattar Alshryda, MBChB, MRCS, FRCS(T&O), MSc, PhD
Lisa Jackson, FRCGP, FHEA, PGCertMedEd
Nandu Thalange, FRCP, FRCPCH, FHEA
Dubai, United Arab Emirates Ali Alhammadi, MBBS
xiiiContents
Part I General
Orthopaedic Terminology �������������������������������������������������������������������������������� 3
Liam Walker and Ling Hong Lee
Normal Development ���������������������������������������������������������������������������������������� 23
Wafa Binfadil, Tahani Al Ali, and Samantha Ismaile
General Assessment ������������������������������������������������������������������������������������������ 39
Sonia Chaudhry and Zarana R. Swarup
Normal Variants ������������������������������������������������������������������������������������������������ 63
Tahani Al Ali, Jihad Saeed, and Sattar Alshryda
Musculoskeletal Infection���������������������������������������������������������������������������������� 87
Stephanie N. Moore-Lotridge, Michael A. Benvenuti, Isaac P. Thomsen,
and Jonathan G. Schoenecker
Musculoskeletal Tumors������������������������������������������������������������������������������������ 113
Mohamed Ahmed Mashhour
Metabolic Bone Disease ������������������������������������������������������������������������������������ 145
Ahmed Nugud, Alaa Nugud, Sattar Alshryda, and Nandu Thalange
Neuromuscular Conditions ������������������������������������������������������������������������������ 171
Samena Chaudhry, Heather Read, and Sattar Alshryda
Relevant Syndromes������������������������������������������������������������������������������������������ 207
Sarah Rubin and Jan Sochon-Smith
Musculoskeletal Dysplasias ������������������������������������������������������������������������������ 231
Sania Shahid and Deborah M. Eastwood
Limb Deformity�������������������������������������������������������������������������������������������������� 263
Mohamed Kenawey, Zullie Ali, and Farhan Ali
Child Safeguarding�������������������������������������������������������������������������������������������� 283
Themistoklis Tzatzairis, Maria Nivatsi, and Claudia Maizen
xvxvi Contents Chronic Pain in Children���������������������������������������������������������������������������������� 293 Thanthullu Vasu and Alwyn Abraham Part II Region Specific Topics Paediatric Hips �������������������������������������������������������������������������������������������������� 309 Lydia R. Belcher, Michael A. Benvenuti, Perry L. Schoenecker, and Jonathan G. Schoenecker Paediatric Knee Disorders�������������������������������������������������������������������������������� 349 Sumukh Khandekar and Stan Jones Paediatric Foot and Ankle�������������������������������������������������������������������������������� 377 Om Lahoti and Nisha Patel Paediatric Spine ������������������������������������������������������������������������������������������������ 403 Hayder Saleh Al-Saadi and Firas Dakhil-Jerew Paediatric Shoulder Disorders�������������������������������������������������������������������������� 429 David Hawkes, H. S. Lloyd, and Matthew Nixon Paediatric Elbow������������������������������������������������������������������������������������������������ 451 Robert Wilson and Neil Wilson Paediatric Hand and Wrist ������������������������������������������������������������������������������ 473 Anastasios Chytas and Gillian Smith
Contributors
Alwyn Abraham University Hospitals of Leicester NHS Trust, Leicester, UK
Tahani Al Ali Al Jalila Children’s Speciality Hospital, Dubai, United Arab Emirates
Farhan Ali Royal Manchester Children’s Hospital, Manchester University NHS
Foundation Trust, Manchester, UK
Zullie Ali Royal Manchester Children’s Hospital, Manchester University NHS
Foundation Trust, Manchester, UK
Hayder Saleh Al-Saadi Spinal Surgeon, Rashid Hospital, Dubai, United Arab Emirates
Sattar Alshryda, MBChB, MRCS, FRCS(T&O), MSc, PhD Head of Trauma
& Orthopaedics Surgery, Al Jalila Children’s Speciality Hospital, Dubai, United
Arab Emirates
Anastasios Chytas Royal Manchester Children Hospital, Manchester, UK
Lydia R. Belcher Paediatric Orthopaedics Vanderbilt University, Monroe Carrell
Jr Children’s Hospital, Nashville, TN, USA
Michael A. Benvenuti Vanderbilt University Medical Center, Nashville, TN, USA
Monroe-Carrel Children’s Hospital, Pediatric Orthopaedics and Infectious Disease,
Nashville, TN, USA
Wafa Binfadil Al Jalila Children’s Speciality Hospital, Dubai, United Arab Emirates
Samena Chaudhry Royal Stoke University Hospital, Stoke-on-Trent, UK
Sonia Chaudhry University of Connecticut School of Medicine, Farmington, USA
Pediatric Orthopaedic and Hand Surgeon, Connecticut Children’s Medical Center,
Hartford, USA
Firas Dakhil-Jerew Australian GP Group, Sydney, Australia
Matthew Debenham Middlemore Hospital, Auckland, New Zealand
Deborah M. Eastwood Great Ormond St Hospital and the Royal National
Orthopaedic Hospital, Stanmore, UK
University College London, London, UK
xviixviii Contributors David Hawkes Trauma and Orthopaedics Registrar, Countess of Chester Hospital, Chester, UK Orthopaedic Department, Countess of Chester Health Park, Chester, UK Samantha Ismaile The Higher Colleges of Technology, Dubai, United Arab Emirates Stan Jones Al Ahli Hospital, Doha, Qatar Sumukh Khandekar Al Ahli Hospital, Doha, Qatar Mohamed Kenawey Royal Manchester Children’s Hospital, Manchester University NHS Foundation Trust, Manchester, UK Om Lahoti King’s College Hospital, London, UK Ling Hong Lee Consultant Trauma and Orthopaedics/Paediatric Orthopaedics, Sunderland Royal Hospital, Sunderland, UK H. S. Lloyd Mosgiel Health Centre, Mosgiel, New Zealand Best Practice Advocacy Centre (BPAC), Dunedin, New Zealand Department of General Practice and Rural Health, University of Otago, Dunedin, New Zealand Mohamed Ahmed Mashhour Department of Orthopedic Surgery, Faculty of Medicine, Ain Sham University, Orthopedic Oncology Unit, Cairo, Egypt Orthopedic Surgery, Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU), Dubai, United Arab Emirates Claudia Maizen Royal London Hospital, Paediatric Orthopaedics, London, UK Stephanie N. Moore-Lotridge Vanderbilt University Medical Center, Nashville, TN, USA Monroe-Carrel Children’s Hospital, Pediatric Orthopaedics and Infectious Disease, Nashville, TN, USA Maria Nivatsi Pediatric Department, University Hospital of Alexandroupolis, Alexandroupolis, Greece Matthew Nixon Trauma and Orthopaedic Consultant, Countess of Chester Hospital, Chester, UK Ahmed Nugud Al Jalila Children’s Speciality Hospital, Dubai, United Arab Emirates Alaa Nugud Latifa Women’s and Children’s Hospital, Dubai Health Authority, Dubai, United Arab Emirates Nisha Patel Urgent Care Center – Emergency Department, Kings College Hospital, London, UK Heather Read Royal Hospital for Children, Glasgow, UK
Contributors xix Sarah Rubin Village Community Medical Centre, Derby, UK Jihad Saeed Al Jalila Children’s Speciality Hospital, Dubai, United Arab Emirates Perry L. Schoenecker Paediatric Orthopaedics Washington University, St. Louis Children’s Hospital, St. Louis, MO, USA Jonathan G. Schoenecker Vanderbilt University Medical Center, Nashville, TN, USA Monroe-Carrel Children’s Hospital, Pediatric Orthopaedics and Infectious Disease, Nashville, TN, USA Zille S. Shah Al Kowthar Practice, Oldham Primary Care, Manchester, UK Sania Shahid Latifa Women and Children Hospital, Dubai, United Arab Emirates Gillian Smith Great Ormond Street Children Hospital, London, UK Jan Sochon-Smith Village Community Medical Centre, Derby, UK Zarana R. Swarup Pediatrician, Children’s Hospital of Philadelphia Primary Care, Philadelphia, PA, USA Nandu Thalange, FRCP, FRCPCH, FHEA Consultant Paediatric Endocrinologist, Department of Medical Subspecialties, Al Jalila Children’s Hospital, Dubai, United Arab Emirates Isaac P. Thomsen Vanderbilt University Medical Center, Nashville, TN, USA Monroe-Carrel Children’s Hospital, Pediatric Orthopaedics and Infectious Disease, Nashville, TN, USA Themistoklis Tzatzairis Royal London Hospital, Paediatric Orthopaedics, London, UK Thanthullu Vasu University Hospitals of Leicester NHS Trust, Leicester, UK Liam Walker GP Registrar, Health Education England North East, Newcastle, UK Neil Wilson Consultant, Royal Hospital for Children, Glasgow, UK Robert Wilson GP, Kenmure Medical Practice, Glasgow, UK
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